Treatment for a Stab Wound with Impaled Object and Cardiac Arrest Answer Key

A 22-year-old man was stabbed in the chest with a large knife. The patient is pulseless and apneic, and the knife is impaled in the center of his chest. Treatment should include: • A:stabilizing the knife, starting CPR, and providing rapid transport. • B:removing the knife, applying an occlusive dressing, and providing rapid transport. • C:removing the knife, starting CPR, and providing rapid transport. • D:stabilizing the knife, applying an occlusive dressing, and providing rapid transport. - The correct answer is C; Reason: There are two indications for removing an impaled object: when the object is causing airway compromise and when the object interferes with your ability to perform CPR. A knife impaled in the center of the chest, which is where chest compressions are performed, in a patient who is in cardiac arrest must be carefully removed. Quickly cover the wound to control any bleeding (an occlusive dressing covered by a sterile dressing is preferred) and begin CPR immediately. A 23-year-old unrestrained female struck the steering wheel with her chest when her passenger car collided with a tree at a high rate of speed. Your assessment reveals that she is conscious, but has signs of shock and an irregular pulse. The MOST appropriate treatment for this patient includes: • A:high-flow oxygen, summoning a paramedic unit to the scene to assess her cardiac rhythm, a cervical collar, and transport as soon as possible. • B:insertion of an oral airway, assisted ventilations with a bag-mask device, full spinal precautions, and rapid transport. • C:applying an AED in case she develops cardiac arrest, high-flow oxygen, full spinal precautions, and rapid transport. • D:high-flow oxygen or assisted ventilations as needed, full spinal precautions, blankets to keep her warm, and rapid transport. - You selected D; This is correct! Reason: The cause of this patient's shock may be a myocardial contusion, or bruising of the heart muscle. Blunt trauma to the chest can injure the heart, making it unable to maintain adequate blood pressure. In a myocardial contusion, the pulse is often irregular, but dangerous rhythms (eg, VFib, V-Tach) are relatively uncommon. There is no special diagnostic test at this time, and there is no prehospital treatment for the condition. Therefore, waiting at the scene for a paramedic unit would only waste time. Apply high-flow oxygen, assist ventilations if the patient is breathing inadequately (eg, slow or fast respirations, shallow breathing [reduced tidal volume]), treat the patient for shock (eg, cover her with blankets, elevate her lower extremities [if local protocol permits]), and transport rapidly. Because of the mechanism of injury, full spinal precautions should be taken. The patient is conscious and likely has an intact gag reflex; therefore, an oral airway is contraindicated. The AED is only applied to patients who are in cardiac arrest A 24-year-old female presents with a rash to her left leg and swollen, painful knee joints. She tells you that she and her friends returned from a hiking trip in the mountains a week ago. She is conscious and alert with a blood pressure of 112/62 mm Hg, a pulse of 84 beats/min, and respirations of 14 breaths/min. Her symptoms are MOST likely the result of: • A:Rocky Mountain spotted fever. • B:tetanus. • C:Lyme disease. • D:a localized allergic reaction. - You selected C; This is correct! Reason:The patient's symptoms and her history of a recent hiking trip are consistent with Lyme disease, which was the result of a tick bite. Ticks can carry two infectious diseases: Lyme disease and Rocky Mountain spotted fever. Both are spread through the tick's saliva, which is injected into the skin when the tick attaches itself. The first symptom of Lyme disease, a rash that may spread to several parts of the body, begins about 3 days after the bite of an infected tick. The rash may eventually resemble a target bull's-eye pattern in one third of patients. After a few more days or weeks, painful swelling of the joints, particularly the knees, occurs. If recognized and treated promptly with antibiotics, many patients recover completely. Rocky Mountain spotted fever, which is not limited to the Rocky Mountains, occurs within 7 to 10 days after being bitten by an infected tick. Its symptoms include nausea, vomiting, headache, weakness, paralysis, and possibly cardiopulmonary failure. A 28-year-old woman has severe lower quadrant abdominal pain. When assessing her abdomen, you should: • A:encourage the patient to lie supine with her legs fully extended. • B:ask her where the pain is located and palpate that area first. • C:auscultate for bowel sounds for approximately 2 to 5 minutes. • D:ask her where the pain is located and palpate that area last - You selected D; This is correct! Reason:Assessment of a patient's abdomen includes asking where the pain is located and then palpating that area last. Palpating the painful area first may interfere with the rest of your assessment because of the significant pain the patient will be in. Bowel sounds are of little value in the field and generally are not included in the abdominal assessment. Patients with severe abdominal pain typically prefer to lie on their side with their knees drawn up into their chest (fetal position). Moving them from this position will aggravate their pain. A 29-year-old woman, who is 38 weeks pregnant, presents with heavy vaginal bleeding, a blood pressure of 70/50 mm Hg, and a heart rate of 130 beats/min. She is pale and diaphoretic, and denies abdominal cramping or pain. Her signs and symptoms are MOST consistent with a/an: • A:placenta previa. • B:abruptio placenta. • C:ruptured ectopic pregnancy. • D:ruptured ovarian cyst. - The correct answer is A; Reason:Of the conditions listed, placenta previa would be the least likely to present with abdominal pain, although some patients may have pain or cramping. Placenta previa is a condition in which the placenta develops over and covers some or all of the cervix. As the cervix dilates, the vasculature that attaches the placenta to the uterine wall tears, resulting in vaginal bleeding that is often severe enough to cause shock. By contrast, abruptio placenta is a condition in which the placenta prematurely separates from the uterine wall; it is characterized by tearing abdominal pain, heavy vaginal bleeding, and shock. Placenta previa and abruptio placenta occur during the later stages of pregnancy. A ruptured ovarian cyst typically causes lower abdominal pain, often unilateral. Ectopic pregnancy, a condition in which the egg implants and grows outside the uterus (usually in a fallopian tube), is a first trimester condition; it is typically discovered between 8 and 10 weeks of pregnancy. If the ectopic pregnancy ruptures, the patient often presents with a sudden stabbing pain in the lower abdomen and shock due to intraabdominal hemorrhage. A 30-year-old man sustained partial-thickness burns to the anterior chest and both anterior arms. Based on the Rule of Nines, what percentage of his body surface area has been burned? • A:36% • B:9% • C:18% • D:27% - The correct answer is C; Reason: According to the adult Rule of Nines, the anterior trunk (chest and abdomen) accounts for 18% of the total body surface area (TBSA) and each entire arm accounts for 9%. Therefore, the anterior chest, which is one half of the trunk, would account for 9% of the TBSA, and both anterior arms (4.5% each) would account for 9% TBSA, for a total of 18% TBSA burned. A 30-year-old man with a history of schizophrenia cut his wrists and is bleeding profusely. He is confused, combative, and has slurred speech. With the assistance of law enforcement personnel, you and your partner physically restrain him in order to provide care and transport. In this situation, a court of law would MOST likely: • A:conclude that you should have had a court order to restrain. • B:determine that the patient had decision-making capacity. • C:agree that you and your partner are guilty of assault and battery. • D:consider your actions in providing care to be appropriate. - You selected D; This is correct! Reason:An adult with decision-making capacity (ie, a mentally competent adult) has the legal right to refuse medical treatment, even if that treatment involves lifesaving care. In psychiatric cases, however, a court of law would likely consider your actions in providing lifesaving care to be appropriate, particularly if you have a reasonable belief that the patient would harm him- or herself or others without your intervention. In addition, a patient who is in any way impaired, whether by mental illness, medical condition, or intoxication, may not be considered competent to refuse treatment and transport. If you are unsure of a patient's decision-making capacity, err on the side of treatment and transport. Few would argue that it would be easier to defend why you treated a patient than to justify or defend why you abandoned a patient. A 30-year-old woman crashed her car into a tree at a high rate of speed. She is conscious and alert and has stable vital signs. She has some small lacerations and abrasions to her arms and face, but no obviously life-threatening injuries. As you are loading her into the ambulance, she tells you that she does not want to go to the hospital. You should: • A:advise her that she is probably too emotionally upset to be able to refuse EMS treatment and transport. • B:obtain a signed refusal from the patient and ask a law enforcement officer to transport her to the hospital. • C:advise the patient that she should be transported to the hospital because of the seriousness of the crash. • D:ask a law enforcement officer to administer a breathalyzer test to determine if she has been drinking alcohol. - You selected C; This is correct! Reason:The consequences of refusal should be explained to any patient who refuses EMS treatment and/or transport. After establishing that the patient can legally refuse treatment and transport (eg, he or she is of legal age AND has decision-making capacity), you must advise her that because of the significant mechanism of injury, the potential for critical injury or death exists, even though she may feel fine now. Once this is explained, and the patient understands and is willing to accept the possible consequences, obtain a signed refusal and ask an impartial person (eg, police officer) to witness the signed refusal.